Pressure injuries · 8 min
Pressure injury litigation: avoidable or unavoidable, records and expert selection
The federal standard does not ask whether a wound developed. It asks whether the facility did everything the resident's condition required.
The test
Under F686, a resident who enters the facility without pressure ulcers should not develop them unless the individual's clinical condition demonstrates that they were unavoidable, and a resident with an existing ulcer must receive the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Surveyor guidance frames unavoidability as a sequence: the facility evaluated the resident's condition and risk factors, defined and implemented interventions consistent with resident needs, goals and professional standards, monitored and evaluated the impact of those interventions, and revised them as appropriate.
That sequence is the outline of both sides' cases. The defense will argue every step was performed and the wound still occurred. The plaintiff will show a step that is missing from the record.
Where the sequence usually breaks
- Risk was scored once on admission and never rescored after decline, surgery, or hospitalisation
- Interventions were ordered but the delivery records do not show them being performed
- Repositioning documentation is identical across shifts, which suggests charting rather than care
- The support surface was ordered but there is no delivery, rental, or maintenance record
- Weight loss and poor intake continued for weeks before a dietitian was consulted
- The wound advanced a stage and the physician and family were told days later
- The care plan was never revised as the wound worsened
Staging and mimics
Accurate classification matters because it drives both liability and damages. Deep tissue pressure injury, unstageable injury covered by eschar, moisture-associated skin damage, arterial and venous ulcers, diabetic foot ulcers, and skin failure at end of life are distinct entities. Facilities sometimes label a pressure injury as moisture damage, and plaintiffs sometimes treat an arterial ulcer as a pressure ulcer. A wound-certified expert sorts this out from the measurements, descriptions, photographs, and vascular history.
When unavoidable is a fair answer
Some wounds truly are unavoidable. Severe peripheral arterial disease, refusal of care by a resident with capacity, hemodynamic instability where turning is contraindicated, and the skin changes associated with the dying process can all support that conclusion, but only if the chart shows the facility recognised the situation, documented it, and continued to do what it could. Unavoidability argued for the first time in a deposition, with no contemporaneous documentation, rarely survives.
Damages evidence
Photographs with a measurement reference, weekly measurement trends, debridement and surgical records, pain assessments, infection and sepsis records, and hospital admissions attributable to the wound. In death cases, the death certificate and autopsy language about sepsis or the wound carry particular weight with juries.
This page is educational and is not legal advice. Regulatory citations reflect CMS State Operations Manual Appendix PP and 42 CFR Part 483; confirm the version in effect for your matter.
